PERMISSION TO REPRINT PUBLISHED MATERIAL
Date: __________________________
_____________________ (the “Owner”) has received the request of
____________________ (the “Requestor”), in a letter dated _____________________,
_____, to reproduce the Material (as defined below). The Owner hereby grants the
request on the following terms and conditions, which terms and conditions the Requestor
hereby accepts:
(1) The published work (the “Original Work”) that is the subject of this agreement
(the “Agreement”) is the following:
Author:
Title:
Name of Publication:
Date of Original Publication:
The Owner is the sole copyright holder of the Original Work.
(2) Permission is hereby granted to use the following selection from the Original
Work:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
(the “Material”). The Material represents approximately _________ % of the
Original Work. [A copy of the Material is attached to this Agreement.]
(3) The Material may be used only as follows, without deletions from, additions to, or
changes in the text thereof:
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
__________________________________________________________________
_______________________________________________________________.
(4) The Material [will not be used in a seminar or other educational activity] [will be
used in a seminar or other educational activity as follows:
__________________________________________________________________
__________________________________________________________________
_______________________________________________________________.]
(5) In consideration for the grant of the Owner’s permission to use the Material, the
Requestor agrees to pay a one time fee of $__________________ (the “Fee”).
The permissions granted under this Agreement shall be ineffective until the Fee is
paid in